Case Study

RPA solution for claim approval automation

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Background

Canada-based leading healthcare insurance company had 20 people team in Claim Approval Department. The team was handling incoming claim requests generated at empaneled hospitals both through emails and by directly answering policy holders.

Challenge

The staff in Claim Approval Department needed continuous training on different request formats across multiple hospitals and on new policy features. The approval process was inefficient with the following key challenges:

Long approval process taking up to 48 hours
High manpower costs including both salaries and training costs

Solution

Working closely with the client team, Xponentium designed and implemented RPA solution to automate the claim approval process. Xponentium developed bots for

Reading all incoming emails for claim approvals
Identify the correct policy holder and policy number
Get policy details from internal database
Apply all policy terms and conditions to establish eligibility for the claim
Check with already availed insurance coverage and approve the insurance coverage
Send cases to human operator if claim has insufficient coverage limit or is non-compliant with terms and conditions
Intimate the approvals to hospital and policyholders via automated Email/SMS

Impact

Our solution was able to pass through the HIPAA Audit without any hiccups. We followed best practices to ensure the HIPAA Compliance.
Claim Approval Team reduced from 20 people to 4 people reducing efforts in training and human errors
Overall 85% cost reduction on yearly basis resulting from reduction in manpower, training, human errors and automation of manual efforts and communication